Provider Demographics
NPI:1376172015
Name:DESHOMMES, WIDDLER (MD)
Entity Type:Individual
Prefix:
First Name:WIDDLER
Middle Name:
Last Name:DESHOMMES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 ROUZER ST
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-3650
Mailing Address - Country:US
Mailing Address - Phone:407-575-0943
Mailing Address - Fax:
Practice Address - Street 1:4601 N HIGHWAY 19A
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2039
Practice Address - Country:US
Practice Address - Phone:352-290-8718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-04
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR023661208D00000X
PR000229-P.A363A00000X
AZ8363363A00000X
FLTPPA363363A00000X
FLACN1610208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant